The diagnosis was functional paraplegia plus left internal popliteal neuritis. The crutches were removed, he was isolated, and given motor reëducation. In a week he was able to walk alone with ease.
Re popliteal nerve lesions, Athanassio-Benisty remarks that the external popliteal nerve of the leg resembles pathologically the musculospiral nerve of the arm, whereas the internal popliteal behaves like the median. The musculospiral nerve of the arm shows very variable and usually slight sensory changes. The median nerve more than any other nerve in the arm yields painful sensations during its recovery from section.
Re differentiation of peripheral neuritis and hysterical paralysis, Babinski gives as signs peculiar to neuritis, and never found in hysterical paralysis, the following: (a) diminution or loss of bone and tendon reflexes; (b) muscular atrophy (except for slight amyotrophy exceptionally found in hysteria); (c) the reaction of degeneration (only of value after eight or ten days); (d) hypotonus; (e) distribution characteristic of peripheral motor sensory and trophic disorder.
Re diagnosis of organic paraplegia as against hysterical paraplegia, the latter is to be recognized chiefly by the absence of the organic signs, as (a) alteration of tendon reflexes, (b) the Babinski sign (toe phenomenon), (c) exaggeration of defense reflexes (dorsal flexion of foot on sharp pinching of dorsum of foot or leg), (d) muscular atrophy with R. D., (e) sphincter disorder, (f) skin changes, such as decubitus.
Bullet in hip: Local “stupor” of leg.
Case 388. (Sebileau, November, 1914.)
A Moroccan sharpshooter, 20, was wounded September 27, at Soissons. One bullet scratched the left thigh. A second entered below the anterosuperior iliac spine at least 6 cm. outside the femoral artery and emerged above the ischiotrochanteric line, 2 cm. above and 4 cm. behind the upper extremity of the great trochanter, thus passing through the tensor of the fascia lata and without breaking a bone.
There was a complete paralysis of the left leg. The man had to walk with a crutch and a cane, dragging the leg like a weight. There was no active or passive movement of thigh, lower leg and foot muscles, except that there was a slight tendency to abduction of the toes, from innervation of the dorsal interossei of the foot. The iliopsoas was also involved, as well as the gluteal and pelvic trochanteric muscles. There was a certain amount of muscular tone preserved, so that the bony elements of the skeleton were held together. The foot did not fall and the leg did not elongate, as it might have in a case of paralysis of the sciatic nerve. Electro-diagnosis showed an early reaction of degeneration according to one examiner, but Sebileau believes that there was no R. D. There was anesthesia of a large part of the leg, which stretched over the anterior and internal aspects of the thigh, covered the entire territory of obturator and crural nerves but did not stretch above the fold of the groin. The region of the femorocutaneous nerve was slightly sensitive and the posterior aspect of the thigh and buttock was sensitive. There was a slight sensation on the external aspect of the lower leg. Foot and toes were entirely insensitive. The anesthesia was for all forms of common sensation. No vasomotor, thermic or trophic disorder. The reflexes were all abolished, except for a tendency to cremasteric reflex. It is clear that these conditions cannot be simulated. Possibly they are hysteric and to be explained on the basis of a kind of autosuggestion or perhaps, according to Sebileau, the local and nervous apparatus under the mechanical and caloric effects of the fragment had undergone a sort of local stupor. No large nerve could have been affected by the injury, according to the analysis made by Sebileau.
Re stupor, see [Case 253] of Tinel. Re such local “stupor” it may be noted that this case was published in 1914, before Babinski’s larger publications on reflex disorders. As for the loss of cutaneous reflexes, Babinski remarks that immersion in hot water may cause the cutaneous reflexes in the so-called physiopathic cases to reappear for a time. He regards the loss of cutaneous reflexes in the physiopathic cases as due to a circulatory disturbance, and recalls the fact that compression by an Esmarch bandage can cause the tendon reflexes to vanish for a time, and can even cause pathologically excessive reflexes to disappear. The cutaneous reflexes have also been caused to disappear by compression.